170,000 Medicare patients suspected of doctor shopping for drugs

The GAO urges more controls to prevent fraud, including restrictions on those who seek prescriptions for controlled substances from multiple doctors.

By Charles Fiegl — Posted Oct. 24, 2011

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About 170,000 Medicare patients sought prescriptions for frequently abused drugs from five or more physicians and other health professionals in 2008, a Government Accountability Office analysis of claims data found.

The Oct. 4 report accused 1.8% of the Part D beneficiary population of doctor shopping for one or more of 14 abused drugs, such as painkillers hydrocodone and oxycodone. Spending on the drugs cost the program $148 million, representing 5% of the total spent on these drugs in 2008.

The GAO has called for more fraud controls on the prescription drug benefit to eliminate doctor shopping, including restrictions on those who seek prescriptions for controlled substances from multiple physicians. However, the agency overseeing Medicare Part D, and physician and patient advocacy groups, warned that too much interference could prevent legitimate use of prescriptions.

During a hearing after the report's release, members of the Senate Homeland Security & Governmental Affairs Committee strongly criticized the Centers for Medicare & Medicaid Services for failing to prevent the abuse of prescription medicines. The Drug Enforcement Agency has identified doctor shopping as a diversionary technique to acquire controlled substances. The GAO investigation outlined cases where patients saw dozens of practitioners to obtain narcotics.

"Beyond the fraud and abuse, taxpayer dollars are potentially being used to fuel the illicit prescription drug trade," said Sen. Scott Brown (R, Mass.), the ranking member on the committee.

One Georgia patient obtained prescriptions for a 1,679-day supply of oxycodone pills from 58 prescribers, the GAO said. A physician treating the patient recalled her asking for early refills of the painkiller repeatedly. The patient stopped seeing the physician after he refused to give refills for the drug. Based on the patient's history, the physician said the patient was probably selling the extra narcotics as opposed to taking them, the report said.

A patient in California received prescriptions for fentanyl from 21 prescribers in 2008. The patient's physician later received a letter from the state prescription drug-monitoring program informing her that within a four-month period the patient had 33 prescriptions from 10 prescribers. The physician then notified the patient that she would no longer treat the patient.

The best way to prevent doctor shopping is through state prescription drug-monitoring programs, said AMA President Peter W. Carmel, MD. Some state programs provide information to physicians at the point of care, but that was not the case in 2008.

"Patients often see different physicians for different medical problems, and these physicians write different prescriptions for them," Dr. Carmel said. "Placing limits on how Medicare patients obtain prescription drugs would have many unintended negative consequences."

A small percentage of Medicare patients misuse the Part D benefit, said David Certner, AARP legislative policy director. However, the abuse is a burden on taxpayers and the Medicare program.

"It is important that we eliminate this abuse, which also uses up valuable physician time that should be dedicated to patients with legitimate medical needs," Certner said.

Fighting Part D fraud

CMS agreed that more action should be taken to curb misuse of prescription drugs in Part D. However, the Medicare agency needs to strike a balance between fighting fraud and ensuring patient access to medically necessary prescriptions, wrote Jim Esquea, Dept. of Health and Human Services assistant secretary for legislation, in a memo responding to the GAO report.

The GAO recommended that CMS consider a program limiting doctor-shopping patients to one prescriber, one pharmacy or both for receiving prescriptions. The GAO did not provide evidence that such a policy would be more effective than current controls, Esquea said.

CMS will analyze data on overutilization and questionable access to drugs and issue guidance to Part D plan sponsors on best practices for monitoring.

CMS Deputy Administrator Jonathan Blum told the Senate committee that Part D plans must have concurrent and retrospective drug utilization reviews in place. Concurrent programs perform reviews of prescribed drugs at the point-of-sale in a pharmacy, and retrospective reviews scrub claims data to find patterns of inappropriate use of the drug benefit.

Using electronic prescribing technology also can prevent fraud, Blum said. For instance, an e-prescribing system can show a physician the patient's medication history, prescription doses and when drugs were prescribed.

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Favorite drugs of doctor shoppers

The GAO analyzed 1 billion Medicare Part D claims and found that about 170,000 beneficiaries received prescriptions for one of 14 frequently abused drugs from five or more prescribers in 2008. Most patients accused of doctor shopping received Part D coverage through a disability.

Drug Total
Percodan (Oxycontin, Percocet) 56,837 $91.7 million
Fentanyl (Duragesic) 5,077 $19.1 million
Hydrocodone (Vicodin, Lortab) 97,394 $18.9 million
Morphine (MS Contin, Avinza) 6,391 $9.3 million
Non-benzodiazepine sleep aids (Ambien, Lunesta) 4,511 $2.9 million
Hydormorphone (Dilaudid) 2,551 $1.2 million
Tramadol (Ultram, Ultracet) 4,527 $1.0 million
Amphetamine derivatives (Adderall) 895 $1.0 million
Methadone (Dolophine, Methadose) 3,423 $859,000
Carisoprodol (Soma) 3,083 $593,000
Methylphenidate (Ritalin, Concerta) 743 $489,000
Benzodiazepine (Valium, Xanax) 2,460 $373,000
Codeine with acetaminophen 1,525 $245,000
Meperidine (Demerol) 157 $90,000

Source: "Instances of Questionable Access to Prescription Drugs," Government Accountability Office, Oct. 4 (link)

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